Secondary stroke prevention: Review of clinical trials

Context:Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care-driven health service is an option to ensure optimal care to poststroke patients residing at home in the community.Aims:We assessed outcomes of a pilot long-term stroke care clinic which combined secondary prevention and rehabilitation at community level.Settings and Design:A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility.Subjects and Methods:Analysis of patients was done at initial contact and at 1-year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI).Statistical Analysis Used:Differences in means between baseline and post treatment were compared using paired t-tests or Wilcoxon-signed rank test. Significance level was set at 0.05.Results:Ninety-one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457).Conclusions:Primary care-driven long-term stroke care services yield favorable outcomes for blood pressure control and functional level.

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“…The exact involvement of the primary care team in long-term stroke outcomes, however, remains unclear. [ 17 ]…”

Section: Introductionmentioning

confidence: 99%

What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

Aziz

Nordin

et al. 2013

Journal of Neurosciences in Rural Practice

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“…Possible mechanisms for ARDS development include increased pulmonary vascular permeability and extravascular pulmonary fluid deposits; however, its relation to intracranial pressure (ICP), cerebral perfusion pressure (CPP), and brainstem function have not been well defined. [2][3][4][5][6] Early diagnosis of pulmonary damage allows for early intervention, perhaps decreasing the likelihood of progression to severe forms of ARDS and pneumonia, with the aim of improving the outcome of patients with AIS. Transpulmonary thermodilution allows for the estimation of extravascular fluid in the lungs and vascular permeability in real time, thus facilitating more precise control of hemodynamics.…”

Section: Introductionmentioning

confidence: 99%

Dynamics of Extravascular Pulmonary Water and Intracranial Pressure in Patients With Ischemic Stroke

Вереин

Valiahmedov

Churliaev

et al. 2010

Semin Cardiothorac Vasc Anesth

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The objective of the present study was to examine the relationship among extravascular pulmonary water, intracranial and cerebral perfusion pressure, hemodynamic parameters (eg, cardiac index, system vascular resistance index), and brain stem function during acute ischemic stroke. The subjects were 17 comatose patients with ischemic stroke who were admitted to an intensive care unit. The results revealed an elevation in extravascular lung water in the absence of cardiac dysfunction. The absence of correlation between indices of brain vascular resistance and mean arterial pressure confirmed that a disturbance of cerebral blood flow was present. There was a correlation between auditory-evoked potential parameters and extravascular lung water during the study period. The correlation between auditory-evoked potentials and extravascular lung water may imply that ischemic brainstem injury plays a significant role in the development of increased pulmonary capillary permeability and the elevation of extravascular lung water. Brain stem injury is a cause of noncardiogenic lung edema in comatose patients following acute ischemic stroke.

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“…Secondary stroke after initial stroke or transient ischemic attack (TIA) has been reported in approximately 25 to 40% of patients within 5 years of the initial event. 3 Within the first 30 days, 3%-8% of patients experience a repeat attack. 3 Stroke is associated with substantial morbidity and mortality in the United States; 1 in 16 deaths annually are caused by stroke, and 15%-30% of stroke survivors are permanently disabled.…”

Section: Introductionmentioning

confidence: 99%

“…3 Within the first 30 days, 3%-8% of patients experience a repeat attack. 3 Stroke is associated with substantial morbidity and mortality in the United States; 1 in 16 deaths annually are caused by stroke, and 15%-30% of stroke survivors are permanently disabled. 4 In 2007, the estimated annual combined direct and indirect costs of stroke will reach nearly $63 billion.…”

Section: Introductionmentioning

confidence: 99%

Antiplatelet Therapy in Cerebrovascular Disease: Implications of MATCH and CHARISMA Results for Cardiologists

Fintel

2007

Clinical Cardiology

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SummaryCardiovascular disease is prevalent among patients with stroke; thus, cardiologists frequently treat patients at high risk for stroke. Results from recent clinical trials of antiplatelet medications, given alone or in combination, may be of special interest to cardiologists. The Management of Artherothrombosis with Clopidogrel in Highrisk Patients (MATCH) study demonstrated no significant difference between clopidogrel alone and clopidogrel plus aspirin in reducing risk of vascular events after stroke or transient ischemic attack. A 1.3% increased risk of major bleeding was associated with clopidogrel plus aspirin. In the Clopidogrel for High Artherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) study, clopidogrel plus aspirin did not reach statistical significance versus placebo plus aspirin in reducing incidence of myocardial infarction (MI), stroke, or death from cardiovascular causes in patients with stable atherothrombotic disease; clopidogrel was associated with an increase in moderate bleeding. These results suggest that clopidogrel plus aspirin may be inappropriate as first-line therapy for secondary stroke prevention. In patients with established cardiovascular disease at risk for MI or other vascular events, physicians must weigh the benefits and risks before choosing this therapy. Selection of an antiplatelet agent must be based on patient history, including previous MI and stroke, susceptibility to bleeding, and other high-risk factors (e.g., advanced age and diabetes). Aspirin plus extended-release dipyridamole may be more effective than clopidogrel for preventing stroke in high-risk patients. This article strives to put MATCH and CHARISMA results into context by providing an overview of antiplatelet therapy, including relevant clinical trial results, a review of current practice guidelines, and a summary of an ongoing study that will improve clinical decision making.

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Secondary stroke prevention: Review of clinical trials

Cited by 5 publications

References 81 publications

What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

Dynamics of Extravascular Pulmonary Water and Intracranial Pressure in Patients With Ischemic Stroke

Antiplatelet Therapy in Cerebrovascular Disease: Implications of MATCH and CHARISMA Results for Cardiologists

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